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Acupuncture & Insurance, Part 2 — Affordability

Many of us see it as a no-brainer. We want acupuncture to be affordable, insurance/Medicare makes it affordable, how could anyone be against that? This reasoning relies upon a superficial understanding of health care costs and affordability.

Consider:

Affordability must take into account premiums as well as co-pays and out-of-pocket expenses.

Both cost to the individual and sustainability of the system are part of affordability.

All medical costs are ultimately borne by the public.

When coverage is provided for the very sick, the premiums of many healthy people contribute to their medical expenses.

If health care spending exceeds what the insurance companies have planned for, premiums will go up and reimbursements for providers will go down.

Controlling health care spending depends upon providers accepting reduced payment for their services and upon a bureaucracy determining what services are appropriate.

The wealthiest in our system typically have the best insurance coverage.

A respected colleague said I give the impression that Community Acupuncture is the only way for people to get affordable acupuncture and that everyone should treat that way. My bad — I don’t believe that. I do believe it is a good way — it accepts the reality that acupuncture isn’t really more affordable if it doesn’t cost the system less. It provides affordable treatment to everyone, not just to those with the best insurance coverage. And it keeps big business out of treatment decisions.

I continue to treat one client at a time, in a private room. I have a generous sliding scale, available to all, to help a wide range of people afford acupuncture. Some practitioners treat in private rooms and charge one low price to all patients. I have colleagues who reserve a certain percentage of their appointments for those who need steeply discounted services, and I have others who volunteer in free or low-cost clinics. These are all ways to make acupuncture affordable.

Disguising the cost of acupuncture by hiding the expense in co-pays and premiums (many so expensive that they are subsidized by taxpayers) doesn’t make it more affordable. Changing the way you treat so that your reimbursements match what you think you deserve doesn’t make acupuncture more affordable (or support arguments for cost effectiveness).

CA is not the only way to make acupuncture affordable and I certainly don’t think it is the only style of treatment that should be available. But insurance increases the big picture affordability of acupuncture only to the extent that it limits reimbursement rates and access. Insurance is not a magic wand, and those practitioners who believe it is are in for a rude surprise.

For more, check out this post, and these statistics about the increases in health care spending in the US.

20 thoughts on “Acupuncture & Insurance, Part 2 — Affordability”

Glad to find this discussion. All of these are hot topics in Washington state, where state law requires acupuncture to be covered under (most) insurance plans. With the changes from Affordable Healthcare, many companies have limited pre-deductible acupuncture coverage to the higher-priced plans. The whole reason I take insurance is so that I have a varied clientele–I never, ever want to limit myself to treating only wealthier people and patients who have acupuncture benefits are more likely to give it a shot. Employer-funded plans still have decent acupuncture benefits (for the most part) but the many people who buy their own healthcare do not because of the new un-affordability of individual coverage. What’s worse, patients have switched over to the company who reimburses me at the very lowest rate.
All the while, the WA PT Board will release their decision on Friday as to whether or not they’ll include dry needling in their scope. Currently, there are PTs doing dry needling and billing it as manual therapy. (Even worse, a colleague also spotted “A Manual of Acupuncture” in a PT’s office recently. Ugh. )
My point here is that I’ve been getting so riled up about both of these issues and am finally coming to the conclusion that the standard medical model that is under the thumb of the insurance companies is simply not conducive to or respectful of our medicine. Even when it comes to reimbursement rates, I’ve seen the fee schedules that clearly show how much more a MD, DC and even ND get paid for acupuncture than acupuncturists. It’s total bullshit. Furthermore, there are no studies or monitoring of how much money is saved when patients come to us instead of allopathic medical care for various ailments.
I’ve been playing the insurance game for well over a decade now and, while I’ve been successful at it, I’ve had it. So now I’m bracing myself because I am in so deep and it’s going to be a very long road back out again. Not to mention, and I still have about 5 years of student loans to pay off…

Ash — So sorry that you are dealing with this. Based on what I’ve seen happen with other procedures and professions I think it is a safe bet that as more insurance plans cover acupuncture, the reimbursement rates will go down. This will probably happen even more quickly as acupuncturists try to stay ahead by doing more and billing more — it isn’t at all unusual for me to hear that LAcs are billing for three sets of needles and heating pads, manual therapy, etc. That may be what they are doing, but I wonder how many would be doing three sets of needles if it weren’t for the insurance game. And, as the amount they bill goes up, that is going to impact the cost effectiveness. Trust me, insurance companies will collect that data.

BTW — I read that the WA PT Board has postponed the decision — new board members have been appointed and since they weren’t there for the hearing, etc. the decision has been delayed.

Thanks for the well wishes. Luckily, I’m in a position to pay them (I’ve been on the slow road there) but I am so worried for the newbies coming out of school now with even higher debts than I had.
That said, we do good medicine and I am amazed by and proud of it every single day! No insurer is gonna take that away from me!!

Not all acupuncturists do community acupuncture. Probably most have regular private practices.

What’s to say PTs wouldn’t bill out higher than non-community acupuncturists? Since insurance-based practices are their norm, they would go as high as possible. We can’t be sure whether PT involvement will lower or raise the standard acupuncture fee schedule.

Partly what I’m getting at is we need to move cautiously because we have no idea how things will come down in the end.

From what I can tell, insurance companies develop a set fee they will pay for a procedure, and that fee is as low as they can get away with. Based on what I read on the PT Boards that I can access, most insurance does not cover dry needling. There has been a lot of talk about PT’s billing out their dry needling procedures as manual therapy. I have no idea what that pays, but I believe that would be considered fraud — just as it would be for an acupuncturist to bill their time doing cupping as though it was acupuncture.

I agree that we don’t know how things will turn out it the end, but I think a lot of this talk about PT’s being able to extract more from the insurance companies for doing dry needling that we can do for doing acupuncture is 1) mostly fear-based rumor, 2) comes down to who can get away with fraud more easily, and 3) beside the point. I guess one thing to consider — insurance tends to focus on paying for procedures rather than paying for time. One of the professions complaints is that we aren’t “adequately” reimbursed for our diagnostic time and systems evaluation. Dry Needling doesn’t involve a systems evaluation and so takes less time – so dry needling fits the system as a procedure rather than a medicine. I’m still not sure how that should guide our next steps…..

My comment did not come from fear-based conjecture. I meant to paint it as a positive – that PTs doing acupuncture might actually raise the reimbursement rate for the procedure, which can only help us. As you said, it’s the procedure they pay for, not who is doing it. We would get the same reimbursement for performing the same procedure as a PT or other provider.

Unfortunately, I was not separating acupuncture & dry needling in this thought process, being more focused on the idea that it might help us if a higher fee was assigned to acupuncture.

As you know, I think the whole insurance/acupuncture thing is problematic. All the services paid for by insurance are ultimately paid for by the consumer, through premiums. Insurance makes sense for very expensive conditions that happen infrequently — less so for run-of-the mill stuff. So, every time I hear conversations about increasing reimbursements all I can think about is how much my premiums will go up…..

Just recently I found out that my favorite doctor in town (and a great referral source) has started a new division of his practice…..private pay. He stopped taking new clients years ago (capped out at 1,400 clients). He spends a ton of time with his clients and is dedicated to figuring out their health issues. He decided to start the private cash practice to move away from insurance. For $275 a month, he will be your private physician. No limit on dr visits/phone calls or duration of the time spent with him. He’s frustrated with the limitation of insurance.

I understand that this is not uncommon, but it’s my first experience with it first hand. It tells me how bad insurance functions.

In regards to pain management, I am concerned that other practitioners such as PT will become the cheaper way for clients to get acupuncture. Insurance will always look at the best way to pay less.

Thanks, Samantha. Again, I think it has been a mistake for the profession to equate dry needling and acupuncture. By continuing to stress what makes us different, both in training and in our focus on overall well being, we could educate the public.

It will be interesting — if patients do well with dry needling from PT’s, then we’ve disproven our whole argument that our training is extra-special. If they don’t do well with treatment from PT’s, then this whole “fad” will blow over and we’ve got nothing to worry about.

Interestingly, for all the talk about PT’s getting rich off of dry needling, insurance typically does not cover it. One of the reasons they might be interested in expanding into it — it is a cash service.

I think it also comes down to schooling. I never received proper pain management classes. Thus I decided to take the sports medicine class in NYC. It’s not enough to treat pain with minimal training and expect great results. I think it’s part of the reason PTs get good results. They know how to evaluated the client and determine what needs to be needled.

I am a firm believer acupuncturists can’t be passive in training and then expect insurance or even cash paying clients to want us for their treatment process.

I don’t understand your attitude about pain. What better place to start is there? So many people suffer from chronic pain, then they suffer from the medications used to treat chronic pain, then they suffer from depression because the drugs do not eliminate the pain, and then they suffer from the antidepressant drugs. Pain is the reason most people seek acupuncture and when they feel the difference with the first treatment (or first needle insertion) they know that acupuncture really works. Meanwhile, the acupuncturists, who know that chronic pain is a symptom of something deeper, can educate their patients, and treat the root issues. Patients who feel results really listen to their practitioners and are often able to make nutritional or lifestyle changes that dramatically improve long term health.

This is why acupuncture is so cost effective. Not only can it do away with the need for the surgery, medication, or dialysis, but it saves patients from the cost and suffering caused by side effects. Medications work by disrupting communication in the body which leads to side effects and more expensive medications and procedures. Acupuncture and Chinese herbs improve communication in the body. This is why our patients routinely see improvements in other symptoms (collateral benefits) while getting acupuncture treatments.

The magnitude of direct cost savings between back surgery which has poor long term outcome statistics (costing between fifty thousand dollars and ninety thousand dollars) and a series of 20 $90 acupuncture treatments is huge. 25 X to 50 X cheaper. Indirect savings from eliminating the risks of complications, post surgical medications & physical therapy, and time spent recuperating would easily pay for the acupuncture by themselves.

Hey, David, thanks for continuing the conversation. I think I may have done a poor job of explaining my attitude about treating pain. I think acupuncture is great for pain. I think it is wonderful that when people come for pain we have an opportunity to explore and treat the underlying issues that lead to that pain. I do think that if we look at the impact on overall health and wellbeing from acupuncture it is absolutely cost effective. Yea acupuncture!

I am not clear that the way acupuncture will be allowed into the system, and the way acupuncturists will adapt their treatments to work the system, will permit these benefits to be realized. If a plan allows six acupuncture visits, that will likely not be enough to obtain lasting pain relief or address the deeper issues or perhaps even negate the need for surgery.

If each post were long enough to explore these issues in their entirety no one would read them — and I’d need to find some way to make this a paying gig. Sorry about that. What I was trying to share was that, while it is easy to talk about acupuncture and affordability, it isn’t as easy as, we get coverage, everyone experiences affordable and effective treatment. The limits the system puts on what and how we treat, the way we adjust our billing and coding to make the system work for us, the outcomes that matter to the insurance companies, and the many payments that individuals make into the system — through co-pays, premiums, co-insurance, etc. all need to be in the mix when we talk about affordable acupuncture.

I think David makes a good point but I would go further. I have no doubt that everyone else has the same experience I have, a new patient calls and the first question out of their mouth is “do you take insurance?” I always take a breath and go through the whole pricing/sliding scale rationale, but the way the question is framed is as if it is up to me, as if it is my decision to take insurance or not. In my state, very very few plans cover acupuncture. Some will, if it’s performed by an MD or DC, and some will if you’re in network, which acupuncturists cannot join, which is something I also have to explain. Now let me be clear, I don’t want to participate in insurance billing, but I think it colors people’s perception of us and what we do. I don’t think it would lower costs or increase acupuncturist’s revenue, but I do think more people would choose acupuncture if it was part of their insurance plan, even if they had a co pay and a high deductible and even if it ended up costing them the same or even more. I think being in the insurance framework lends an air of medical legitimacy. Yesterday, I had a worker’s comp case manager give me a long detailed profile of a patient she wanted to refer for acupuncture (she had been approved for ONE visit). At the end of the conversation, I explained to her I’m not a doctor or chiropractor, but I am licensed to do acupuncture. There was an audible gasp. She hurriedly said she would have to consult with her supervisor and get back to me. Another thing that happens frequently is after several (or sometimes one) treatment a patient will say, “wow, this stuff is great, why won’t insurance pay for this?” It doesn’t matter what I say, they are feeling somehow vaguely ripped off, they pay good money for their insurance and from their point of view why shouldn’t it cover a treatment that works for them? What can I tell them? If we were in California, Blue Cross would pay, but in Illinois, acupuncture is considered “experimental,” unless you have a good union, in which case it will pay. Again, I’m not saying I want to get into the insurance game, I’m just saying from a patient’s perspective, it looks strange, even suspect. This points to what is the bigger question for me, “Is acupuncture really a part of our medical system?” Acupuncture is not quite a “medical” procedure in the sense of being conceptually congruent with the rest of our medical system, but it is something more than a simple stress relieving treatment. Of course it is both simultaneously and more and thus occupies a unique but amorphous space.

Thanks for contributing! It is true that being part of the system would bring some advantages and would smooth out some of the initial barriers than can interfere with people accessing acupuncture. And I think it is important that we don’t present the advantages without considering the disadvantages. Talk to MD’s about the impact of third-party payer systems on the quality of care they deliver and their own personal job satisfaction and it’s clear that for many they don’t think it has been a good change for medicine or for the profession.
If, ten years down the line, acupuncture is widely accepted and considered a go to first line treatment, six visits before surgery, reimbursed at $20.00, and provided by LAc assistants whose treatment plans are signed off on by the LAc, who pops in for 5 minutes on the 1st and 4th visit, have we done the public and the medicine any good?
I am not trying to present my ponderings on these issues as the “right” answer. I only want us to think through all the implications of our choices. They all come with good and bad.

I am very ambivalent about insurance coverage for acupuncture. Insurance coverage comes with a steep price including outside bureaucracies setting limits on coverage and reimbursement, time spent processing claims, and the risk of insurance audits demanding years of payback for minor mistakes in billing.

But, I don’t understand how insurance coverage of acupuncture will increase health care costs because “All medical costs are ultimately borne by the public”. Acupuncture is a very cost effective treatment option and has the potential to significantly reduce medical costs if used instead of surgical intervention or even “standard care” medications and physical therapy.

I also think availability and acceptability at least as important as affordability. It is true that “the wealthiest in our system typically have the best insurance coverage”, but it is also true that most people in our system have some health insurance. When their doctor recommends that they try acupuncture they ask “is it covered by insurance”? When the doctor truthfully says, “maybe, but not likely” they get referred to physical therapy.

Insurance coverage will make acupuncture more available and acceptable and more people will have acupuncture than before. On the other hand, you are definitely right about it being full of rude surprises for acupuncturists.

David — Thanks for your comments. Here is what comes up for me around cost effectiveness and affordability. First off, when thinking about cost effectiveness, what do we mean? The first issue is cost — are we talking about a short series of treatments, or ongoing treatments? Treatments at a CA rate of $20.00/visit, or the going rate in my area of around $90.00. As for effectiveness, does the treatment do away with the need for the surgery or medication, or just postpone it or decrease the dosage? The games practitioners pay to enable increased reimbursement — like coding for a condition that is no longer the motivation for ongoing treatment, or upcoding to increase reimbursement — all impact cost effectiveness.

There are now six states in which acupuncture is an EHB, so the MD could answer, yes, acupuncture is covered, in which case the bureaucracy you mention kicks in. The patient is enthusiastic until they find out the condition they have is not covered, or there is no one in their area that accepts their insurance, or they begin to get better after six visits at which time they’ve reached their limit for that condition, or they realize they still have a big deductible to get through. Would’t it be easier if the MD could answer, maybe, or, you can go to this CA clinic and get unlimited treatment for less than your co-pay would be with insurance?

As for going to a PT instead — that will only happen if structural pain is what sent them to the MD. Once upon a time, we used to be so proud that our medicine did not focus on pain. And one of our great contributions to affordable medicine could be through the treatment of other chronic medical conditions. We’ve lost that conversation — ironically, at least partially because of insurance — they’ll cover pain treatment, so that’s what we talk about and that’s what we sell. If we honored our roots as a complete medicine, and if we weren’t fighting for the insurance $, we could let the PT’s take dry needling and help release all those trigger points, while we spent our time getting to the heart of the matter.

I hate to be the one to say it, but dry needling can and often does resolve an issue in 6 sessions. Traditional Chinese Medicine can go farther and treat the root, but if the symptoms are not quickly and effectively addressed, then the problem will continue with murky results and take a very long time to heal. We need to understand that along with the dry needling the PT is trained to assess the biomechanical problem and set up a measurable baseline (ROM or muscle strength testing for example) before tx then get a measurable outcome after tx. His/her assessment will point to a very specific treatment and then the PT is trained to offer specific homecare treatment. Our schools are barely training us to do this if at all. This issue isn’t just about PTs using needles it’s about them administering acupuncture in a way that fits into the existing medical system in a way we dont. Fitting into the existing medical system includes insurance, MD referrals and speaking the language of medicine which is based on anatomy and biomechanics. There will always be new modalities incorporating parts of what we do. Look at what PTs have to endure from Physical Trainers, and Psychiatrists from Psychologists, then Psychologists from Psychotherapists. If we actually fit into the existing medical paradigm ourselves, we wouldn’t be so in danger of getting overlooked. We’re newcomers here we cannot bring the whole medical system to our level we have to make our services relevant to patient needs who have choices within an existing medical system.

This brings up some interesting things — mainly, if we fit ourselves into the current medical system, what have we lost. And, can we even do it. I’ve recently been reading some acupuncture malpractice policies which stress that, at least when it comes to GYN conditions, we’re only supposed to be treating from a Acupuncture-world differential diagnosis. We aren’t to say we are treating fibroids, for instance. Also, insurance is very likely to limit us to treating pain in six treatments rather than getting to the root.

Regular readers of my blog know that my default opinion is that we’d have been better off keeping ourselves beside the existing system (which still included referrals) rather than fitting in and thereby losing some of (much of) what was of value. If we can make things directly affordable — and I think there are ways to do it — then we can avoid the fate of those who have been priced in to becoming supervisors of those providing care. (PT’s and PT Assts., for instance.)

You don’t have to apologize for stating that PT Dry Needling can be effective. It’s true — and also true that for all the talk about it being acupuncture, most LAcs are not adept at the technique.

Elaine,
Great point about insurance:
1. Acupuncture riders (sp?) are an additional cost to the buyer of the policy. Many policies don’t even have acupuncture benefits, since the cost is too much.
2. The best acupuncture benefits are on policies of the wealthy, such as high paid employees.

As a self employed person, my insurance has a high deductible ($5,000). So does my policy cover acupuncture – nope. If it did would I reach my cap? Probable not.

I find it funny that many practitioners want acupuncture coverage for their clients. Yet, insurance coverage for a sole practitioner is step. Does acupuncture insurance coverage make insurance more affordable for the self employed? I doubt it.